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Professor Nicholas is a Emeritus Professor of International Business at University of Newcastle. He was elected to the Academy of the Social Science in Australia in 1997. Between 2014-2019, Professor Nicholas was a High-end Foreign Expert of the State Administration for Foreign Experts and Tianjin 1000 Talents Expert, China, located at Tianjin Normal University. He is currently a Visiting Professor, Beijing Foreign Studies University and Visiting Professor Guangdong University of Foreign Studies. He was Yunshan Chair Professor at the Guangdong University of Foreign Studies (2012-2015) and Guest Professor at Beijing Normal University (2011-2014) and Nanjing University of Finance and Economics (2010-2014). His recent publications include Journal of Medical Internet Research, BMC Public Health, International Journal of Nursing Practice, Journal of Affective Disorders, Health Policy and Planning, Journal of International Business Studies, Personnel Review, Journal of Business Research, Business History, Journal of Economic History, Oxford Economic Papers,
Background All aging societies face the challenge of allocating limited resources for the highest value of use. The sharing economy provides one method to address the imbalance between the demand and supply of health services to the older adult population. With a substantial aging population, China’s practices in the sharing aging industry may set examples for other “getting old before getting rich” countries. Objective There is a gap in both the data and research on China’s aging industry sharing economy. This paper addresses these data and research lacunae by constructing a framework for the application of a sharing model in China’s aging industry, by assessing the current state of the aging industry sharing economy, by setting out the challenges to the sharing aging health care and service economy, and by making recommendations for the development of the aging industry sharing economy. Methods This paper constructs a sharing economy framework in the aging industry covering four aspects (people, facilities, capital, and information) to test the current state and future prospects of China’s aging industry sharing economy. Results In people sharing, we analyzed the sharing of emotional companionship, doctors, nurses, nursing attendants, and domestic helpers. We discussed facility sharing models from the point of land and housing, medical devices, and other items such as pensioner meals and shared medicine bins. We acknowledge that crowdfunding platforms have developed fast in China, but many older adult users faced problems in their operation. Information sharing is a developing field, which can optimize users’ experiences and should help older adults filter out misinformation, but China currently does not have adequate sharing information platforms for older adults. Conclusions We identified four major challenges in China’s aging industry sharing economy: poor adaptability to technology for older adults, mediocre quality of shared services, one-size-fits-all and the concept of the useless elderly, and shortage of qualified practitioners. We make recommendations for specific measures by governments, communities, and enterprises to improve the sharing economy in the aging industry.
Yaolin Hu; Jian Wang; Stephen Nicholas; Elizabeth Maitland. The Sharing Economy in China’s Aging Industry: Applications, Challenges, and Recommendations. Journal of Medical Internet Research 2021, 23, e27758 .
AMA StyleYaolin Hu, Jian Wang, Stephen Nicholas, Elizabeth Maitland. The Sharing Economy in China’s Aging Industry: Applications, Challenges, and Recommendations. Journal of Medical Internet Research. 2021; 23 (7):e27758.
Chicago/Turabian StyleYaolin Hu; Jian Wang; Stephen Nicholas; Elizabeth Maitland. 2021. "The Sharing Economy in China’s Aging Industry: Applications, Challenges, and Recommendations." Journal of Medical Internet Research 23, no. 7: e27758.
By applying advanced health information technology to the health care field, health informatization helps optimize health resource allocation, improve health care services, and realize universal health coverage. COVID-19 has tested the status quo of China’s health informatization, revealing challenges to the health care system. This viewpoint evaluates the development, status quo, and practice of China’s health informatization, especially during COVID-19, and makes recommendations to address the health informatization challenges. We collected, assessed, and evaluated data on the development of China’s health informatization from five perspectives—health information infrastructure, information technology (IT) applications, financial and intellectual investment, health resource allocation, and standard system—and discussed the status quo of the internet plus health care service pattern during COVID-19. The main data sources included China’s policy documents and national plans on health informatization, commercial and public welfare sources and websites, public reports, institutional reports, and academic papers. In particular, we extracted data from the 2019 National Health Informatization Survey released by the National Health Commission in China. We found that China developed its health information infrastructure and IT applications, made significant financial and intellectual informatization investments, and improved health resource allocations. Tested during COVID-19, China’s current health informatization system, especially the internet plus health care system, has played a crucial role in monitoring and controlling the pandemic and allocating medical resources. However, an uneven distribution of health resources and insufficient financial and intellectual investment continue to challenge China’s health informatization. China’s rapid development of health informatization played a crucial role during COVID-19, providing a reference point for global pandemic prevention and control. To further promote health informatization, China’s health informatization needs to strengthen top-level design, increase investment and training, upgrade the health infrastructure and IT applications, and improve internet plus health care services.
Mian Huang; Jian Wang; Stephen Nicholas; Elizabeth Maitland; Ziyue Guo. Development, Status Quo, and Challenges to China’s Health Informatization During COVID-19: Evaluation and Recommendations. Journal of Medical Internet Research 2021, 23, e27345 .
AMA StyleMian Huang, Jian Wang, Stephen Nicholas, Elizabeth Maitland, Ziyue Guo. Development, Status Quo, and Challenges to China’s Health Informatization During COVID-19: Evaluation and Recommendations. Journal of Medical Internet Research. 2021; 23 (6):e27345.
Chicago/Turabian StyleMian Huang; Jian Wang; Stephen Nicholas; Elizabeth Maitland; Ziyue Guo. 2021. "Development, Status Quo, and Challenges to China’s Health Informatization During COVID-19: Evaluation and Recommendations." Journal of Medical Internet Research 23, no. 6: e27345.
(1) Background: By April 2021, over 160 million Chinese have been vaccinated against coronavirus disease 2019 (COVID-19). This study analyzed the impact of vaccination on discrimination against recovered COVID-19 patients and the determinants of discrimination among intended vaccinated people. (2) Methods: A self-designed questionnaire was used to collect data on COVID-19 associated discrimination from nine provinces in China. Pearson chi-square tests and a multivariate ordered logistic regression analyzed the determinants of COVID-19-related discrimination. (3) Results: People who intended to be COVID-19 vaccinated displayed a high level of discrimination against recovered COVID-19 patients, with only 37.74% of the intended vaccinated without any prejudice and 34.11% displaying severe discrimination. However, vaccinations reduced COVID-19-related discrimination against recovered COVID-19 patients from 79.76% to 62.26%. Sex, age, education level, occupation, geographical region, respondents’ awareness of vaccine effectiveness and infection risk, and COVID-19 knowledge score had a significant influence on the COVID-19 related discrimination (p < 0.05). (4) Conclusions: Vaccination significantly reduced COVID-19 associated discrimination, but discrimination rates remained high. Among the intended vaccinated respondents, females, the older aged, people with high school and above education level, retirees, migrant workers, and residents in central China were identified as key targets for information campaigns to reduce COVID-19 related discrimination.
Lu Li; Jian Wang; Anli Leng; Stephen Nicholas; Elizabeth Maitland; Rugang Liu. Will COVID-19 Vaccinations End Discrimination against COVID-19 Patients in China? New Evidence on Recovered COVID-19 Patients. Vaccines 2021, 9, 490 .
AMA StyleLu Li, Jian Wang, Anli Leng, Stephen Nicholas, Elizabeth Maitland, Rugang Liu. Will COVID-19 Vaccinations End Discrimination against COVID-19 Patients in China? New Evidence on Recovered COVID-19 Patients. Vaccines. 2021; 9 (5):490.
Chicago/Turabian StyleLu Li; Jian Wang; Anli Leng; Stephen Nicholas; Elizabeth Maitland; Rugang Liu. 2021. "Will COVID-19 Vaccinations End Discrimination against COVID-19 Patients in China? New Evidence on Recovered COVID-19 Patients." Vaccines 9, no. 5: 490.
(1) Background: More coronavirus disease 2019 (COVID-19) vaccines are gradually being developed and marketed. Improving the vaccination intention will be the key to increasing the vaccination rate in the future; (2) Methods: A self-designed questionnaire was used to collect data on COVID-19 vaccination intentions, protection motivation and control variables. Pearson Chi-square test and multivariate ordered logistic regression models were specified to analyze the determinants of intention to receive COVID-19 vaccine; (3) Results: Although the vaccine was free, 17.75% of the 2377 respondents did not want, or were hesitant, to receive the COVID-19 vaccine. Respondents’ cognition of vaccine safety, external reward and response efficacy were positively related to COVID-19 vaccination intention, while age, income and response cost were negatively related to the intention to receive the COVID-19 vaccine. Professionals and people without medical insurance had the lowest intention to vaccinate; (4) Conclusions: The older aged, people without health insurance, those with higher incomes and professionals should be treated as the key intervention targets. Strengthening publicity and education about the safety and efficacy of COVID-19 vaccines, training vaccinated people and community leaders as propagandists for the vaccine, and improving the accessibility to the COVID-19 vaccine are recommended to improve COVID-19 vaccination intention.
Lu Li; Jian Wang; Stephen Nicholas; Elizabeth Maitland; Anli Leng; Rugang Liu. The Intention to Receive the COVID-19 Vaccine in China: Insights from Protection Motivation Theory. Vaccines 2021, 9, 445 .
AMA StyleLu Li, Jian Wang, Stephen Nicholas, Elizabeth Maitland, Anli Leng, Rugang Liu. The Intention to Receive the COVID-19 Vaccine in China: Insights from Protection Motivation Theory. Vaccines. 2021; 9 (5):445.
Chicago/Turabian StyleLu Li; Jian Wang; Stephen Nicholas; Elizabeth Maitland; Anli Leng; Rugang Liu. 2021. "The Intention to Receive the COVID-19 Vaccine in China: Insights from Protection Motivation Theory." Vaccines 9, no. 5: 445.
(1) Background: China will provide free coronavirus disease 2019 (COVID-19) vaccinations for the entire population. This study analyzed the COVID-19 vaccination willingness rate (VWR) and its determinants under China’s free vaccination policy compared to a paid vaccine. (2) Methods: Data on 2377 respondents were collected through a nationwide questionnaire survey. Multivariate ordered logistic regression models were specified to explore the correlation between the VWR and its determinants. (3) Results: China’s free vaccination policy for COVID-19 increased the VWR from 73.62% to 82.25% of the respondents. Concerns about the safety and side-effects were the primary reason for participants’ unwillingness to be vaccinated against COVID-19. Age, medical insurance and vaccine safety were significant determinants of the COVID-19 VWR for both the paid and free vaccine. Income, occupation and vaccine effectiveness were significant determinants of the COVID-19 VWR for the free vaccine. (4) Conclusions: Free vaccinations increased the COVID-19 VWR significantly. People over the age of 58 and without medical insurance should be treated as the target intervention population for improving the COVID-19 VWR. Contrary to previous research, high-income groups and professional workers should be intervention targets to improve the COVID-19 VWR. Strengthening nationwide publicity and education on COVID-19 vaccine safety and effectiveness are recommended policies for decision-makers.
Rugang Liu; Yuxun Zhang; Stephen Nicholas; Anli Leng; Elizabeth Maitland; Jian Wang. COVID-19 Vaccination Willingness among Chinese Adults under the Free Vaccination Policy. Vaccines 2021, 9, 292 .
AMA StyleRugang Liu, Yuxun Zhang, Stephen Nicholas, Anli Leng, Elizabeth Maitland, Jian Wang. COVID-19 Vaccination Willingness among Chinese Adults under the Free Vaccination Policy. Vaccines. 2021; 9 (3):292.
Chicago/Turabian StyleRugang Liu; Yuxun Zhang; Stephen Nicholas; Anli Leng; Elizabeth Maitland; Jian Wang. 2021. "COVID-19 Vaccination Willingness among Chinese Adults under the Free Vaccination Policy." Vaccines 9, no. 3: 292.
BACKGROUND All aging societies face the challenge of allocating limited resources for the highest value of use. The sharing economy provides one method to address the imbalance between the demand and supply of health services to the older adult population. With a substantial aging population, China’s practices in the sharing aging industry may set examples for other “getting old before getting rich” countries. OBJECTIVE There is a gap in both the data and research on China’s aging industry sharing economy. This paper addresses these data and research lacunae by constructing a framework for the application of a sharing model in China’s aging industry, by assessing the current state of the aging industry sharing economy, by setting out the challenges to the sharing aging health care and service economy, and by making recommendations for the development of the aging industry sharing economy. METHODS This paper constructs a sharing economy framework in the aging industry covering four aspects (people, facilities, capital, and information) to test the current state and future prospects of China’s aging industry sharing economy. RESULTS In people sharing, we analyzed the sharing of emotional companionship, doctors, nurses, nursing attendants, and domestic helpers. We discussed facility sharing models from the point of land and housing, medical devices, and other items such as pensioner meals and shared medicine bins. We acknowledge that crowdfunding platforms have developed fast in China, but many older adult users faced problems in their operation. Information sharing is a developing field, which can optimize users’ experiences and should help older adults filter out misinformation, but China currently does not have adequate sharing information platforms for older adults. CONCLUSIONS We identified four major challenges in China’s aging industry sharing economy: poor adaptability to technology for older adults, mediocre quality of shared services, one-size-fits-all and the concept of the useless elderly, and shortage of qualified practitioners. We make recommendations for specific measures by governments, communities, and enterprises to improve the sharing economy in the aging industry.
Yaolin Hu; Jian Wang; Stephen Nicholas; Elizabeth Maitland. The Sharing Economy in China’s Aging Industry: Applications, Challenges, and Recommendations (Preprint). 2021, 1 .
AMA StyleYaolin Hu, Jian Wang, Stephen Nicholas, Elizabeth Maitland. The Sharing Economy in China’s Aging Industry: Applications, Challenges, and Recommendations (Preprint). . 2021; ():1.
Chicago/Turabian StyleYaolin Hu; Jian Wang; Stephen Nicholas; Elizabeth Maitland. 2021. "The Sharing Economy in China’s Aging Industry: Applications, Challenges, and Recommendations (Preprint)." , no. : 1.
UNSTRUCTURED By applying advanced health information technology to the health care field, health informatization helps optimize health resource allocation, improve health care services, and realize universal health coverage. COVID-19 has tested the status quo of China’s health informatization, revealing challenges to the health care system. This viewpoint evaluates the development, status quo, and practice of China’s health informatization, especially during COVID-19, and makes recommendations to address the health informatization challenges. We collected, assessed, and evaluated data on the development of China’s health informatization from five perspectives—health information infrastructure, information technology (IT) applications, financial and intellectual investment, health resource allocation, and standard system—and discussed the status quo of the internet plus health care service pattern during COVID-19. The main data sources included China’s policy documents and national plans on health informatization, commercial and public welfare sources and websites, public reports, institutional reports, and academic papers. In particular, we extracted data from the 2019 National Health Informatization Survey released by the National Health Commission in China. We found that China developed its health information infrastructure and IT applications, made significant financial and intellectual informatization investments, and improved health resource allocations. Tested during COVID-19, China’s current health informatization system, especially the internet plus health care system, has played a crucial role in monitoring and controlling the pandemic and allocating medical resources. However, an uneven distribution of health resources and insufficient financial and intellectual investment continue to challenge China’s health informatization. China’s rapid development of health informatization played a crucial role during COVID-19, providing a reference point for global pandemic prevention and control. To further promote health informatization, China’s health informatization needs to strengthen top-level design, increase investment and training, upgrade the health infrastructure and IT applications, and improve internet plus health care services.
Mian Huang; Jian Wang; Stephen Nicholas; Elizabeth Maitland; Ziyue Guo. Development, Status Quo, and Challenges to China’s Health Informatization During COVID-19: Evaluation and Recommendations (Preprint). 2021, 1 .
AMA StyleMian Huang, Jian Wang, Stephen Nicholas, Elizabeth Maitland, Ziyue Guo. Development, Status Quo, and Challenges to China’s Health Informatization During COVID-19: Evaluation and Recommendations (Preprint). . 2021; ():1.
Chicago/Turabian StyleMian Huang; Jian Wang; Stephen Nicholas; Elizabeth Maitland; Ziyue Guo. 2021. "Development, Status Quo, and Challenges to China’s Health Informatization During COVID-19: Evaluation and Recommendations (Preprint)." , no. : 1.
Drawing on team innovation and mood-as-information theories, this paper develops a moderated mediation model to explain the effect of environmental dynamism on team innovative capability. We argue that this effect occurs through an increase in cognitive diversity and is contingent on positive mood, which engenders a more expansive and flexible approach to problem solving. Data collected through a survey-based study of 63 US healthcare teams generates support for our arguments that environmental dynamism increases innovative capability and does so through cognitive diversity. Further, our data suggest that this path only exists when teams are characterized by positive mood. Overall, we find support for a moderated mediation model in which environmental dynamism increases innovative capability through cognitive diversity contingent on positive mood, which allows us to contribute significantly to literature on team innovative capability and mood-as-information.
Rebecca Mitchell; Brendan Boyle; Stephen Nicholas. Team innovative capability: Does positive mood unlock the innovative potential of environmental cues? Journal of Business Research 2021, 126, 376 -384.
AMA StyleRebecca Mitchell, Brendan Boyle, Stephen Nicholas. Team innovative capability: Does positive mood unlock the innovative potential of environmental cues? Journal of Business Research. 2021; 126 ():376-384.
Chicago/Turabian StyleRebecca Mitchell; Brendan Boyle; Stephen Nicholas. 2021. "Team innovative capability: Does positive mood unlock the innovative potential of environmental cues?" Journal of Business Research 126, no. : 376-384.
(1) Background: The management of multiple chronic diseases challenges China’s health system, but current research has neglected how multimorbidity is associated with poor health-related quality of life (HRQOL) and high health service demands by middle-aged and older adults. (2) Methods: A cross-sectional study was conducted in Shandong province, China in 2018 across three age groups: Middle-aged (45 to 59 years), young-old (60 to 74 years), and old-old (75 or above years). The information about socio-economic, health-related behaviors, HRQOL, and health service utilization was collected via face-to-face structured questionnaires. The EQ-5D-3L instrument, comprising a health description system and a visual analog scale (VAS), was used to measure participants’ HRQOL, and χ2 tests and the one-way ANOVA test were used to analyze differences in socio-demographic factors and HRQOL among the different age groups. Logistic regression models estimated the associations between lifestyle factors, health service utilization, and multimorbidity across age groups. (3) Results: There were 17,867 adults aged 45 or above in our sample, with 9259 (51.82%) female and 65.60% living in rural areas. Compared with the middle-aged adults, the young-old and old-old were more likely to be single and to have a lower level of education and income, with the old-old having lower levels than the young-old (P < 0.001). We found that 2465 (13.80%) suffered multimorbidities of whom 75.21% were older persons (aged 60 or above). As age increased, both the mean values of EQ-5D utility and the VAS scale decreased, displaying an inverse trend to the increase in the number of chronic diseases (P < 0.05). Ex-smokers and physical check-ups for middle or young-old respondents and overweight/obesity for all participants (P < 0.05) were positively correlated with multimorbidity. Drinking within the past month for all participants (P < 0.001), and daily tooth-brushing for middle (P < 0.05) and young-old participants (P < 0.001), were negatively associated with multimorbidity. Multimorbidities increased service utilization including outpatient and inpatient visits and taking self-medicine; and the probability of health utilization was the lowest for the old-old multimorbid patients (P < 0.001). (4) Conclusions: The prevalence and decline in HRQOL of multimorbid middle-aged and older-aged people were severe in Shandong province. Old patients also faced limited access to health services. We recommend early prevention and intervention to address the prevalence of middle-aged and old-aged multimorbidity. Further, the government should set-up special treatment channels for multiple chronic disease sufferers, improve medical insurance policies for the older-aged groups, and set-up multiple chronic disease insurance to effectively alleviate the costs of medical utilization caused by economic pressure for outpatients and inpatients with chronic diseases.
Qinfeng Zhao; Jian Wang; Stephen Nicholas; Elizabeth Maitland; Jingjie Sun; Chen Jiao; Lizheng Xu; Anli Leng. Health-Related Quality of Life and Health Service Use among Multimorbid Middle-Aged and Older-Aged Adults in China: A Cross-Sectional Study in Shandong Province. International Journal of Environmental Research and Public Health 2020, 17, 9261 .
AMA StyleQinfeng Zhao, Jian Wang, Stephen Nicholas, Elizabeth Maitland, Jingjie Sun, Chen Jiao, Lizheng Xu, Anli Leng. Health-Related Quality of Life and Health Service Use among Multimorbid Middle-Aged and Older-Aged Adults in China: A Cross-Sectional Study in Shandong Province. International Journal of Environmental Research and Public Health. 2020; 17 (24):9261.
Chicago/Turabian StyleQinfeng Zhao; Jian Wang; Stephen Nicholas; Elizabeth Maitland; Jingjie Sun; Chen Jiao; Lizheng Xu; Anli Leng. 2020. "Health-Related Quality of Life and Health Service Use among Multimorbid Middle-Aged and Older-Aged Adults in China: A Cross-Sectional Study in Shandong Province." International Journal of Environmental Research and Public Health 17, no. 24: 9261.
Vaccinations are an effective choice to stop disease outbreaks, including COVID-19. There is little research on individuals' COVID-19 vaccination decision-making. We aimed to determine individual preferences for COVID-19 vaccinations in China, and to assess the factors influencing vaccination decision-making to facilitate vaccination coverage. A D-efficient discrete choice experiment was conducted across six Chinese provinces selected by the stratified random sampling method. Vaccine choice sets were constructed using seven attributes: vaccine effectiveness, side-effects, accessibility, number of doses, vaccination sites, duration of vaccine protection, and proportion of acquaintances vaccinated. Conditional logit and latent class models were used to identify preferences. Although all seven attributes were proved to significantly influence respondents’ vaccination decision, vaccine effectiveness, side-effects and proportion of acquaintances vaccinated were the most important. We also found a higher probability of vaccinating when the vaccine was more effective; risks of serious side effects were small; vaccinations were free and voluntary; the fewer the number of doses; the longer the protection duration; and the higher the proportion of acquaintances vaccinated. Higher local vaccine coverage created altruistic herd incentives to vaccinate rather than free-rider problems. The predicted vaccination uptake of the optimal vaccination scenario in our study was 84.77%. Preference heterogeneity was substantial. Individuals who were older, had a lower education level, lower income, higher trust in the vaccine and higher perceived risk of infection, displayed a higher probability to vaccinate. Preference heterogeneity among individuals should lead health authorities to address the diversity of expectations about COVID-19 vaccinations. To maximize COVID-19 vaccine uptake, health authorities should promote vaccine effectiveness; pro-actively communicate the absence or presence of vaccine side effects; and ensure rapid and wide media communication about local vaccine coverage.
Anli Leng; Elizabeth Maitland; Siyuan Wang; Stephen Nicholas; Rugang Liu; Jian Wang. Individual preferences for COVID-19 vaccination in China. Vaccine 2020, 39, 247 -254.
AMA StyleAnli Leng, Elizabeth Maitland, Siyuan Wang, Stephen Nicholas, Rugang Liu, Jian Wang. Individual preferences for COVID-19 vaccination in China. Vaccine. 2020; 39 (2):247-254.
Chicago/Turabian StyleAnli Leng; Elizabeth Maitland; Siyuan Wang; Stephen Nicholas; Rugang Liu; Jian Wang. 2020. "Individual preferences for COVID-19 vaccination in China." Vaccine 39, no. 2: 247-254.
(1) Background: The association between multimorbidity and mental health is well established. However, the role of gender in different populations remains unclear. Currently, China is facing an increased prevalence of multimorbidity, especially in its disease-causing poverty population. The present study explores the gender-based differences in the relationship between multimorbidity and mental health using data from the rural, disease-causing poverty, older-age population in Shandong province, China, as a case study. (2) Methods: The data were obtained from the survey on the health and welfare of disease-causing poverty households in rural Shandong province. We identified 936 rural participants who were over 60 years old from disease-causing poverty households. The mental health status was measured using the Kessler Psychological Distress Scale (K10) instrument. Using a multivariable linear regression model, including the interaction of gender and multimorbidity, gender differences in the association between multimorbidity and mental health were explored. (3) Results: Multimorbidity was a serious health problem in rural, disease-causing poverty, older-age households, with the prevalence of multimorbidity estimated as 40% for women and 35.4% for men. There was a strong association between multimorbidity and mental health, which was moderated by gender. Women had higher K10 scores than men, and the mean K10 score was highest in women with three or more chronic diseases. Compared with men, women with multimorbidity had a higher risk of mental health problems. (4) Conclusions: The prevalence of multimorbidity in older-age rural disease-causing poverty subpopulations is a severe public health problem in China. The association between multimorbidity and mental health differed by gender, where multimorbid women suffered an increased mental health risk compared with men. Gender differences should be addressed when delivering effective physical and mental healthcare support to disease-causing poverty, older-age, rural households.
Chen Jiao; Anli Leng; Stephen Nicholas; Elizabeth Maitland; Jian Wang; Qinfeng Zhao; Lizheng Xu; Chaofan Gong. Multimorbidity and Mental Health: The Role of Gender among Disease-Causing Poverty, Rural, Aged Households in China. International Journal of Environmental Research and Public Health 2020, 17, 8855 .
AMA StyleChen Jiao, Anli Leng, Stephen Nicholas, Elizabeth Maitland, Jian Wang, Qinfeng Zhao, Lizheng Xu, Chaofan Gong. Multimorbidity and Mental Health: The Role of Gender among Disease-Causing Poverty, Rural, Aged Households in China. International Journal of Environmental Research and Public Health. 2020; 17 (23):8855.
Chicago/Turabian StyleChen Jiao; Anli Leng; Stephen Nicholas; Elizabeth Maitland; Jian Wang; Qinfeng Zhao; Lizheng Xu; Chaofan Gong. 2020. "Multimorbidity and Mental Health: The Role of Gender among Disease-Causing Poverty, Rural, Aged Households in China." International Journal of Environmental Research and Public Health 17, no. 23: 8855.
Background In the prevention and control of infectious diseases, previous research on the application of big data technology has mainly focused on the early warning and early monitoring of infectious diseases. Although the application of big data technology for COVID-19 warning and monitoring remain important tasks, prevention of the disease’s rapid spread and reduction of its impact on society are currently the most pressing challenges for the application of big data technology during the COVID-19 pandemic. After the outbreak of COVID-19 in Wuhan, the Chinese government and nongovernmental organizations actively used big data technology to prevent, contain, and control the spread of COVID-19. Objective The aim of this study is to discuss the application of big data technology to prevent, contain, and control COVID-19 in China; draw lessons; and make recommendations. Methods We discuss the data collection methods and key data information that existed in China before the outbreak of COVID-19 and how these data contributed to the prevention and control of COVID-19. Next, we discuss China’s new data collection methods and new information assembled after the outbreak of COVID-19. Based on the data and information collected in China, we analyzed the application of big data technology from the perspectives of data sources, data application logic, data application level, and application results. In addition, we analyzed the issues, challenges, and responses encountered by China in the application of big data technology from four perspectives: data access, data use, data sharing, and data protection. Suggestions for improvements are made for data collection, data circulation, data innovation, and data security to help understand China’s response to the epidemic and to provide lessons for other countries’ prevention and control of COVID-19. Results In the process of the prevention and control of COVID-19 in China, big data technology has played an important role in personal tracking, surveillance and early warning, tracking of the virus’s sources, drug screening, medical treatment, resource allocation, and production recovery. The data used included location and travel data, medical and health data, news media data, government data, online consumption data, data collected by intelligent equipment, and epidemic prevention data. We identified a number of big data problems including low efficiency of data collection, difficulty in guaranteeing data quality, low efficiency of data use, lack of timely data sharing, and data privacy protection issues. To address these problems, we suggest unified data collection standards, innovative use of data, accelerated exchange and circulation of data, and a detailed and rigorous data protection system. Conclusions China has used big data technology to prevent and control COVID-19 in a timely manner. To prevent and control infectious diseases, countries must collect, clean, and integrate data from a wide range of sources; use big data technology to analyze a wide range of big data; create platforms for data analyses and sharing; and address privacy issues in the collection and use of big data.
Jun Wu; Jian Wang; Stephen Nicholas; Elizabeth Maitland; Qiuyan Fan. Application of Big Data Technology for COVID-19 Prevention and Control in China: Lessons and Recommendations. Journal of Medical Internet Research 2020, 22, e21980 .
AMA StyleJun Wu, Jian Wang, Stephen Nicholas, Elizabeth Maitland, Qiuyan Fan. Application of Big Data Technology for COVID-19 Prevention and Control in China: Lessons and Recommendations. Journal of Medical Internet Research. 2020; 22 (10):e21980.
Chicago/Turabian StyleJun Wu; Jian Wang; Stephen Nicholas; Elizabeth Maitland; Qiuyan Fan. 2020. "Application of Big Data Technology for COVID-19 Prevention and Control in China: Lessons and Recommendations." Journal of Medical Internet Research 22, no. 10: e21980.
Understanding behavioral factors differences in the preferences for vaccinations can improve predictions of vaccine uptake rates and identify effective policy interventions to increase the demand for vaccinations. In this study, 353 adults in Shandong province in China were interviewed about their preferences for hepatitis B virus (HBV) vaccination. A discrete choice experiment (DCE) was employed to analyze the preference for HBV vaccinations, and a mixed logit model was used to estimate respondent preferences for vaccination attributes included in the DCE. While the protection rate against hepatitis B (HB), duration of protection, risk of side-effects, and vaccination cost were shown to influence adults’ preferences for HBV vaccination, adults valued “99% hepatitis B protection” above other attributes, followed by “20 years’ protection duration” and “1 in 150,000 risk of side-effects”. Individuals with lower time discount rates, non-overconfidence, or higher risk aversion were more likely to choose a vaccine. Lower risk aversion individuals showed a higher preference for lower risk of side-effects. Lower time discount rate individuals showed a higher preference for longer protection duration. Non-overconfidence individuals showed a higher preference for higher hepatitis B protection and cost. Interventions should be targeted to the behavioral determinants impeding vaccination.
Na Guo; Jian Wang; Stephen Nicholas; Elizabeth Maitland; Dawei Zhu. Behavioral Differences in the Preference for Hepatitis B Virus Vaccination: A Discrete Choice Experiment. Vaccines 2020, 8, 527 .
AMA StyleNa Guo, Jian Wang, Stephen Nicholas, Elizabeth Maitland, Dawei Zhu. Behavioral Differences in the Preference for Hepatitis B Virus Vaccination: A Discrete Choice Experiment. Vaccines. 2020; 8 (3):527.
Chicago/Turabian StyleNa Guo; Jian Wang; Stephen Nicholas; Elizabeth Maitland; Dawei Zhu. 2020. "Behavioral Differences in the Preference for Hepatitis B Virus Vaccination: A Discrete Choice Experiment." Vaccines 8, no. 3: 527.
While a nursing intervention program for immobile patients with stroke can improve clinic outcomes, less is known about the cost-effectiveness of these interventions. The goal of this study was to evaluate the cost-effectiveness of the intervention program for immobile patients with stroke in China. A cost-effectiveness analysis alongside a pre-test/post-test (before and after) study was undertaken from a health care perspective. Participants were recruited from 25 hospitals among six provinces or municipal cities in eastern (Guangdong province, Zhejiang province, and Beijing municipal city), western (Sichuan province), and central (Henan province and Hubei province) China. A total of 7,653 immobile stroke patients were included in our sample. Patients in routine care settings were recruited from November 2015 to June 2016, and the recruitment of the intervention group patients was from November 2016 to July 2017. To adjust for potential bias from confounding variables, the 1:1 propensity score matching yielded matched pairs of 2,966 patients in the routine care group and 2,966 patients in the intervention group, with no significant differences in sociodemographic or clinical characteristics between two groups. All patients were followed-up 3 months after enrolment in the study. Total healthcare costs were extracted from the hospital information system, with the health outcome effectiveness of the intervention program measured using the EuroQol five-dimensional questionnaire (EQ-5D) instrument and the cost-effectiveness of the intervention measured by the incremental cost-effectiveness ratio with a time horizon of 3 months. Compared to routine care, the intervention program decreased the total costs of stroke patients by CN¥4,600 (95% confidence interval [CI]: [-7050, -2151]), while increasing quality-adjusted life year 0.009 (95% CI: [0.005, 0.013]). The incremental cost-effectiveness ratios over 3 months was CN¥–517,011 per quality-adjusted life year (95% CI: [-1,111,442, -203,912]). Subgroup analysis reveals that both the health-related quality of life and cost effectiveness improved significantly for ischemic patients and tertiary hospitals patients while for hemorrhagic patients and non-tertiary hospital patients only the health-related quality of life improved significantly. Findings from this first cost-effectiveness analysis in immobile stroke patients provide evidence that an intervention program provided significant cost saving, but mainly in ischemic patients and tertiary hospital patients. Wider adoption of such programs may be a sensible approach to reducing the burden of stroke and for immobile patients more generally.
Hongpeng Liu; Dawei Zhu; Baoyun Song; Jingfen Jin; Yilan Liu; Xianxiu Wen; Shouzhen Cheng; Stephen Nicholas; Xinjuan Wu. Cost-effectiveness of an intervention to improve the quality of nursing care among immobile patients with stroke in China: A multicenter study. International Journal of Nursing Studies 2020, 110, 103703 .
AMA StyleHongpeng Liu, Dawei Zhu, Baoyun Song, Jingfen Jin, Yilan Liu, Xianxiu Wen, Shouzhen Cheng, Stephen Nicholas, Xinjuan Wu. Cost-effectiveness of an intervention to improve the quality of nursing care among immobile patients with stroke in China: A multicenter study. International Journal of Nursing Studies. 2020; 110 ():103703.
Chicago/Turabian StyleHongpeng Liu; Dawei Zhu; Baoyun Song; Jingfen Jin; Yilan Liu; Xianxiu Wen; Shouzhen Cheng; Stephen Nicholas; Xinjuan Wu. 2020. "Cost-effectiveness of an intervention to improve the quality of nursing care among immobile patients with stroke in China: A multicenter study." International Journal of Nursing Studies 110, no. : 103703.
BACKGROUND In the prevention and control of infectious diseases, previous research on the application of big data technology has mainly focused on the early warning and early monitoring of infectious diseases. Although the application of big data technology for COVID-19 warning and monitoring remain important tasks, prevention of the disease’s rapid spread and reduction of its impact on society are currently the most pressing challenges for the application of big data technology during the COVID-19 pandemic. After the outbreak of COVID-19 in Wuhan, the Chinese government and nongovernmental organizations actively used big data technology to prevent, contain, and control the spread of COVID-19. OBJECTIVE The aim of this study is to discuss the application of big data technology to prevent, contain, and control COVID-19 in China; draw lessons; and make recommendations. METHODS We discuss the data collection methods and key data information that existed in China before the outbreak of COVID-19 and how these data contributed to the prevention and control of COVID-19. Next, we discuss China’s new data collection methods and new information assembled after the outbreak of COVID-19. Based on the data and information collected in China, we analyzed the application of big data technology from the perspectives of data sources, data application logic, data application level, and application results. In addition, we analyzed the issues, challenges, and responses encountered by China in the application of big data technology from four perspectives: data access, data use, data sharing, and data protection. Suggestions for improvements are made for data collection, data circulation, data innovation, and data security to help understand China’s response to the epidemic and to provide lessons for other countries’ prevention and control of COVID-19. RESULTS In the process of the prevention and control of COVID-19 in China, big data technology has played an important role in personal tracking, surveillance and early warning, tracking of the virus’s sources, drug screening, medical treatment, resource allocation, and production recovery. The data used included location and travel data, medical and health data, news media data, government data, online consumption data, data collected by intelligent equipment, and epidemic prevention data. We identified a number of big data problems including low efficiency of data collection, difficulty in guaranteeing data quality, low efficiency of data use, lack of timely data sharing, and data privacy protection issues. To address these problems, we suggest unified data collection standards, innovative use of data, accelerated exchange and circulation of data, and a detailed and rigorous data protection system. CONCLUSIONS China has used big data technology to prevent and control COVID-19 in a timely manner. To prevent and control infectious diseases, countries must collect, clean, and integrate data from a wide range of sources; use big data technology to analyze a wide range of big data; create platforms for data analyses and sharing; and address privacy issues in the collection and use of big data.
Jun Wu; Jian Wang; Stephen Nicholas; Elizabeth Maitland; Qiuyan Fan. Application of Big Data Technology for COVID-19 Prevention and Control in China: Lessons and Recommendations (Preprint). 2020, 1 .
AMA StyleJun Wu, Jian Wang, Stephen Nicholas, Elizabeth Maitland, Qiuyan Fan. Application of Big Data Technology for COVID-19 Prevention and Control in China: Lessons and Recommendations (Preprint). . 2020; ():1.
Chicago/Turabian StyleJun Wu; Jian Wang; Stephen Nicholas; Elizabeth Maitland; Qiuyan Fan. 2020. "Application of Big Data Technology for COVID-19 Prevention and Control in China: Lessons and Recommendations (Preprint)." , no. : 1.
Background: Medical debt is a persistent global issue and a crucial and effective indicator of long-term family medical financial burden. This paper fills a research gap on the incidence and causes of medical debt in Chinese low- and middle-income households. Method: Data were obtained from the 2015 China Household Finance Survey, with medical debt measured as borrowings from families, friends and third parties. Tobit regression models were used to analyze the data. The concentration index was employed to measure the extent of socioeconomic inequality in medical debt incidence. Results: We found that 2.42% of middle-income families had medical debt, averaging US$6278.25, or 0.56 times average household yearly income and 3.92% of low-income families had medical debts averaging US$5419.88, which was equivalent to 2.49 times average household yearly income. The concentration index for low and middle-income families’ medical debt was significantly pro-poor. Medical debt impoverished about 10% of all non-poverty households and pushed poverty households deeper into poverty. While catastrophic health expenditure (CHE) was the single most important factor in medical debt, age, education, and health status of householder, hospitalization and types of medical insurance were also significant factors determining medical debt. Conclusions: Using a narrow definition of medical debt, the incidence of medical debt in Chinese low- and middle-income households was relatively low. But, once medical debt happened, it imposed a long-term financial burden on medical indebted families, tipping many low and middle-income households into poverty and imposing on households several years of debt repayments. Further studies need to use broader definitions of medical debt to better assess the long-term financial impact of medical debt on Chinese families. Policy makers need to modify China’s basic medical insurance schemes to manage out-of-pocket, medical debt and CHE and to take account of pre-existing medical debt.
Jiajing Li; Chen Jiao; Stephen Nicholas; Jian Wang; Gong Chen; Jinghua Chang. Impact of Medical Debt on the Financial Welfare of Middle- and Low-Income Families across China. International Journal of Environmental Research and Public Health 2020, 17, 4597 .
AMA StyleJiajing Li, Chen Jiao, Stephen Nicholas, Jian Wang, Gong Chen, Jinghua Chang. Impact of Medical Debt on the Financial Welfare of Middle- and Low-Income Families across China. International Journal of Environmental Research and Public Health. 2020; 17 (12):4597.
Chicago/Turabian StyleJiajing Li; Chen Jiao; Stephen Nicholas; Jian Wang; Gong Chen; Jinghua Chang. 2020. "Impact of Medical Debt on the Financial Welfare of Middle- and Low-Income Families across China." International Journal of Environmental Research and Public Health 17, no. 12: 4597.
Background. Traditional, complementary, and alternative medicine (TCAM) has attracted increasing attention in developed countries, but its mainstream status in China, the home of TCAM, is unclear. Over the period of 2004–2016, we analyze the health resources and health resource utilization of traditional medicine in traditional Chinese medicine (TCM) hospitals in China. Methods. Over 2004–2016, we obtained data from all TCM hospitals in all Chinese provinces to create a hospital-based, longitudinal dataset. TCM health resources and their utilization were measured by two outcome variables: (1) primary outcome variables comprising the proportion of TCM physicians, TCM pharmacists, revenue from TCM drugs, and TCM prescriptions and (2) the secondary outcome variables, as proxies of westernization for TCM hospitals, comprising the number of medical equipment above RMB 10,000 and the proportion of surgery in inpatient visits. We used linear regression models with hospital-fixed effects to analyze time trends for the outcome variables. Results. The number of public TCM hospitals remained stable from 2004 to 2016, while the number of private TCM hospitals increased from 294 in 2004 to 1560 in 2016. There was a small percentage increase in the proportion of TCM physicians (0.280%), TCM pharmacists (0.298%), and revenue from Chinese medicines (0.331%) and TCM prescriptions (1.613%) per hospital per year. Chinese drugs accounted for less than a half of the total drug prescriptions, and accordingly, just one-third of the drug revenue was from Chinese medicines at TCM hospitals. The proportions of physicians, pharmacists, revenue from Chinese drug sales, and traditional medicine prescriptions never reach the 60% benchmark target for mainstream in TCM hospitals. As proxies for Western medicine practices in TCM hospitals, the number of medical equipment above RMB 10,000 rapidly rose by over 13 percent per hospital per year, but the proportion of inpatient surgeries declined by 0.830 percentage points per hospital per year, reflecting a mixed trend in the use of Western medicine practices. Conclusion. For the 2004–2016 period, traditional medicine, although making progress towards the mainstream benchmark of 60% TCM services, was still not mainstream at TCM hospitals.
Xuefeng Shi; Dawei Zhu; Stephen Nicholas; Baolin Hong; Xiaowei Man; Ping He. Is Traditional Chinese Medicine “Mainstream” in China? Trends in Traditional Chinese Medicine Health Resources and Their Utilization in Traditional Chinese Medicine Hospitals from 2004 to 2016. Evidence-Based Complementary and Alternative Medicine 2020, 2020, 1 -8.
AMA StyleXuefeng Shi, Dawei Zhu, Stephen Nicholas, Baolin Hong, Xiaowei Man, Ping He. Is Traditional Chinese Medicine “Mainstream” in China? Trends in Traditional Chinese Medicine Health Resources and Their Utilization in Traditional Chinese Medicine Hospitals from 2004 to 2016. Evidence-Based Complementary and Alternative Medicine. 2020; 2020 ():1-8.
Chicago/Turabian StyleXuefeng Shi; Dawei Zhu; Stephen Nicholas; Baolin Hong; Xiaowei Man; Ping He. 2020. "Is Traditional Chinese Medicine “Mainstream” in China? Trends in Traditional Chinese Medicine Health Resources and Their Utilization in Traditional Chinese Medicine Hospitals from 2004 to 2016." Evidence-Based Complementary and Alternative Medicine 2020, no. : 1-8.
Purpose: Hearing loss has not received sufficient attention, especially in low- and middle-income countries where more than 80% of the people with hearing loss reside. Little is known about the preference for hearing aids among people with hearing loss in developing countries. The aim of this study is to elicit the preferences for hearing aid attributes among rural Chinese adults with moderate or greater hearing loss and examine how preferences vary across different individual socioeconomic characteristics. Patients and Methods: We interviewed 125 adults in two rural counties in Shandong province in China. A discrete choice experiment (DCE) with eight attributes, comprising out-of-pocket (OOP) costs, hearing aid style, effective in quiet settings and noisy settings, feedback (whistling), connectivity, water/sweat resistance and battery life, were employed to examine participants’ preference for hearing aids. Mixed logit models were used for the statistical analyses. Results: While OOP costs, effectiveness in quiet settings, water/sweat resistance and battery life were significantly associated with choosing a hearing aid, rural Chinese adults with moderate or greater hearing loss valued effectiveness in noisy settings above other attributes of hearing aids, followed closely by lack of feedback. The preference of the attributes of OOP costs, in the canal hearing aids, effectiveness in noisy settings, connectivity and battery life varied across individual socioeconomic characteristics including sex, marriage, employment, income and education level. Conclusion: Our study supported the view that the development of noise suppression and feedback cancellation systems remained the main challenge for the hearing aid industry. Since OOP costs were also associated with choosing a hearing aid, the policy advice is to improve reimbursements from insurance schemes and/or reduce the costs of hearing aids.
Dawei Zhu; Xuefeng Shi; Stephen Nicholas; Xin Ye; Siyuan Chen; Ping He. Preferences for Hearing Aid Attributes Among People with Moderate or Greater Hearing Loss in Rural China: A Discrete Choice Experiment. Patient Preference and Adherence 2020, ume 14, 643 -652.
AMA StyleDawei Zhu, Xuefeng Shi, Stephen Nicholas, Xin Ye, Siyuan Chen, Ping He. Preferences for Hearing Aid Attributes Among People with Moderate or Greater Hearing Loss in Rural China: A Discrete Choice Experiment. Patient Preference and Adherence. 2020; ume 14 ():643-652.
Chicago/Turabian StyleDawei Zhu; Xuefeng Shi; Stephen Nicholas; Xin Ye; Siyuan Chen; Ping He. 2020. "Preferences for Hearing Aid Attributes Among People with Moderate or Greater Hearing Loss in Rural China: A Discrete Choice Experiment." Patient Preference and Adherence ume 14, no. : 643-652.
We aimed to analyze regional disparities of health care resources in traditional Chinese medicine (TCM) county hospitals and their time trends, and to assess the changes of regional disparities before and after 2009 health care reforms. We used hospital-based, longitudinal data from all TCM county hospitals in China between 2004 and 2016. To measure the key development features of TCM county hospitals, data were collected on government hospital investment, hospital numbers (the average number of TCM hospitals per county), hospital scale (the number of medical staff and hospital beds) and doctors’ workload (the daily visits and inpatient stays per doctor). We used segmented linear regression to test the time trend for outcome variables. We set a breakpoint at 2011, dividing the pre-reform (2004–2011) and post-reform (2012–2016) periods. After the 2009 health reforms, TCM hospitals continued to display large disparities in the number, scale, and doctors’ workload across the three regions. In the pre-reform period, yearly government subsidies for TCM hospitals in western area were roughly RMB0.6 million (US$89 thousand) more than those in central and eastern region, which increased under the 2009 reforms to roughly RMB2 million (US$298 thousand) more per yer in post-reform period. These increased subsidies saw an increase in the number of TCM hospitals in the western area, partly addressing regional disparities. But there was no improvement in the regional disparities in terms of scale (number of beds) and the doctors’ workload (daily outpatient visits and inpatients per doctor) increased or remained unchanged between the western and other regions. Although TCM hospital number, scale, and doctors’ workload increased over the past 13 years, substantial regional disparities remained. The 2009 health reforms did not significantly change the regional disparities in health care resources, especially between the eastern and western regions.
Dawei Zhu; Xuefeng Shi; Stephen Nicholas; Ping He. Regional disparities in health care resources in traditional Chinese medicine county hospitals in China. PLOS ONE 2020, 15, e0227956 .
AMA StyleDawei Zhu, Xuefeng Shi, Stephen Nicholas, Ping He. Regional disparities in health care resources in traditional Chinese medicine county hospitals in China. PLOS ONE. 2020; 15 (1):e0227956.
Chicago/Turabian StyleDawei Zhu; Xuefeng Shi; Stephen Nicholas; Ping He. 2020. "Regional disparities in health care resources in traditional Chinese medicine county hospitals in China." PLOS ONE 15, no. 1: e0227956.
Background Disease-causing poverty is a serious problem in rural China, where social capital can mediate the disease—poverty relationship. However, there is no generally accepted reliable, robust and viable measure of social capital for China’s unique socio-cultural context. This study adapts for China the widely used Onyx and Bullen social capital measurement scale and tests the validity and reliability of a modified Chinese Onyx-Bullen general scale, the Chinese Onyx-Bullen health scale, for a disease-causing-poverty subpopulation in rural China. Methods We conducted the forward and backward translation procedure and cross-cultural adaptation process to derive the 34 item Chinese Onyx-Bullen general scale. Next we collected through face-to face interviews a sample of disease-causing poverty population in rural Shandong province in China to test a 29 item modified Chinese Onyx-Bullen general scale for a health subpopulation. Most of the rural respondents had no formal work, so 5 work-related items in the Onyx-Bullen general scale were deleted in the Chinese Onyx-Bullen health scale. Exploratory factor analysis was conducted to evaluate the structure, validity, internal consistency and reliability of the Chinese Onyx-Bullen health scale. SPSS21.0 software was used for data analysis. Results A total of 467 people completed the scale. For the 29-item scale, a better simple structure was found when the number of factors was limited to 8. The absolute values of inter-factor correlations were in the range of 0.004 to 0.213 and the Kaiser-Meyer-Olkin value was 0.834. All the eight factors explain a total of 59.51% of the variance. The total scale had a Cronbach’s alpha = 0.868, in which seven of the eight factors had Cronbach’s α greater than 0.5. Conclusion The Chinese health version of the Onyx-Bullen general social capital scale showed an adequate reliability and validity in a rural disease-causing poverty subpopulation in Shandong province, providing the first general, robust, consistent and reliable measure of social capital in China. The Chinese Onyx-Bullen general social capital scale provides a scale for testing social capital in China or for modification along the lines of the Chinese Onyx-Bullen health scale.
Lizheng Xu; Min Guo; Stephen Nicholas; Long Sun; Fan Yang; Jian Wang. Disease causing poverty: adapting the Onyx and Bullen social capital measurement tool for China. BMC Public Health 2020, 20, 1 -10.
AMA StyleLizheng Xu, Min Guo, Stephen Nicholas, Long Sun, Fan Yang, Jian Wang. Disease causing poverty: adapting the Onyx and Bullen social capital measurement tool for China. BMC Public Health. 2020; 20 (1):1-10.
Chicago/Turabian StyleLizheng Xu; Min Guo; Stephen Nicholas; Long Sun; Fan Yang; Jian Wang. 2020. "Disease causing poverty: adapting the Onyx and Bullen social capital measurement tool for China." BMC Public Health 20, no. 1: 1-10.